Anesthesia and analgesia
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Anesthesia and analgesia · Jul 2019
ReviewSafety of Beach Chair Position Shoulder Surgery: A Review of the Current Literature.
Although uncommon, severe neurological events have been reported in patients undergoing shoulder surgery in the beach chair position. The presumed etiology of central nervous system injury is hypotension and subsequent cerebral hypoperfusion that occurs after alterations in positioning under general anesthesia. Most clinical trials have demonstrated that beach chair positioning results in reductions in regional brain oxygenation, cerebral blood flow, and jugular bulb oxygenation, as well as impairment in cerebral autoregulation and electroencephalographic/processed electroencephalographic variables. Further studies are needed to define the incidence of adverse neurological adverse events in the beach chair position, identify the best intraoperative neurological monitors that are predictive of neurocognitive outcomes, the lowest "safe" acceptable blood pressure during surgery for individual patients, and the optimal interventions to treat intraoperative hypotension.
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Anesthesia and analgesia · Jul 2019
ReviewEvidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Bariatric Surgery.
Why is this important?
With obesity rates over 40% in many industrialised countries, and accelerating growth in bariatric surgery for more than a decade, there is need for evidence based guidelines to direct perioperative care.
This evidence review was conducted to identify protocols that achieve "superior outcomes, reduced length of hospital stay, and cost savings" for bariatric patients.
Many of the institutional protocols were founded on ERAS principals originating with colorectal surgery.
Ok, what did they identify?
The AHRQ made evidence-based anesthesia recommendations across three areas:
- Preoperative: reduce fasting; provide carbohydrate loading; multimodal preanesthesia medication.
- Intraoperative: standardised intraoperative anesthesia; protective ventilation; goal-directed fluid therapy (minimization); postop nausea and vomiting prophylaxis.
- Postoperative: multimodal analgesia.
Reality check
These protocols largely reflect 'good quality modern anesthesia', and there is little here that is specific to bariatric patients.
This is not a critcism, but a reminder that it's consistent and holistic application of quality anesthesia across the perioperative period that improves outcomes – especially among higher risk patients. Interventions do not need to be fancy, just quality principles consistently applied.
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Anesthesia and analgesia · Jul 2019
Randomized Controlled TrialThe Effect of Dexmedetomidine on Propofol Requirements During Anesthesia Administered by Bispectral Index-Guided Closed-Loop Anesthesia Delivery System: A Randomized Controlled Study.
Dexmedetomidine, a selective α2-adrenergic agonist currently approved for continuous intensive care unit sedation, is being widely evaluated for its role as a potential anesthetic. The closed-loop anesthesia delivery system (CLADS) is a method to automatically administer propofol total intravenous anesthesia using bi-spectral index (BIS) feedback and attain general anesthesia (GA) steady state with greater consistency. This study assessed whether dexmedetomidine is effective in further lowering the propofol requirements for total intravenous anesthesia facilitated by CLADS. ⋯ The addition of dexmedetomidine to propofol administered by CLADS was associated with a consistent depth of anesthesia along with a significant decrease in propofol requirements, albeit with an incidence of hemodynamic depression and early postoperative sedation.
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Anesthesia and analgesia · Jul 2019
Randomized Controlled TrialHigh-Fidelity Simulation Nurse Training Reduces Unplanned Interruption of Continuous Renal Replacement Therapy Sessions in Critically Ill Patients: The SimHeR Randomized Controlled Trial.
Although continuous renal replacement therapy (CRRT) is common, unplanned interruptions (UI) often limit its usefulness. In many units, nurses are responsible for CRRT management. We hypothesized that a nurse training program based on high-fidelity simulation would reduce the rate of interrupted sessions. ⋯ High-fidelity simulation nurse training reduced the rate of UI of CRRT sessions and the need for nurses to request assistance. This intervention may be particularly useful in the context of frequent nursing staff turnover.
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Anesthesia and analgesia · Jul 2019
Observational StudyTransient Tachypnea of Newborns Is Associated With Maternal Spinal Hypotension During Elective Cesarean Delivery: A Retrospective Cohort Study.
The risk for transient tachypnea of newborns, a common cause of respiratory distress in the neonatal period, is 2- to 6-fold higher during elective cesarean delivery compared to vaginal delivery. Here, we evaluated the association between transient tachypnea of newborns and the degree and duration of predelivery maternal hypotension during spinal anesthesia for elective cesarean delivery. ⋯ Our results suggest that the degree and duration of maternal SBP <90 mm Hg after neuraxial anesthesia during elective cesarean delivery are associated with transient tachypnea of newborns. Future prospective studies should further explore the effects of maternal hypotension, its prevention, and treatment for transient tachypnea of newborns.